การตรวจสอบคุณภาพเวชระเบียนผู้ป่วยในโรงพยาบาลของรัฐ จังหวัดนครปฐม ปี 2549

บทคัดย่อ

       This research aims to study the accuracy of diagnosis, procedure, coding, and completeness of medical audit, compare relative weight before and after audit of government hospital’s medical audit in Nakhon Pathom Province. Cross sectional descriptive study by checking medical audit in 611 cases from 11 government hospitals using percentage, average, standard deviation and x² test and Pair _t-test and considered a relationship with the statistic level at 0.05.

       The result founded that accuracy of the doctor in discharge summary has an accurate of 81.01% compare with statistic to find the different between an accurate and mistake of medical audit. Categorize each hospital found that mistake relation in statistic (P < 0.05). Checking of code assessment found that coding have an accurate of 72.50%. Checking of officer who code assessment found that mistake relation in statistic (P < 0.05) compare with relative weight before and after medical audit. Patient file have relative weight , 66 file about 10.80% average of relative weight before and alter accurate medical audit found that it isn’t different in (P < 0.05). Quality of medical audit is mid-Ievel most of them are 56.34%.

       Suggestion, we should motivate medical officer to realize that medical record is important to summarize and an accurate coding. It is important to hospital quality developing system and hospital finance system. Medical audit should make the memorandum that the important 7 thing that should have in medical audit such as birth, surgery. Every hospital should have internal medical audit team to audit data about twice a year and report the data to hospital committee. The organization that control hospital such as Ministry of Public Health, National Health Insurance Office should develop a team to audit medical record in each province. So that we can bring the medical audit data to benchmarking each province, region, by the size of hospital. The suggestion will be the guideline to develop medical audit to have more quality.